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(BQ) Part 1 book “Clinical assessment of voice” has contents: Patient history, special considerations relating to members of the acting profession, physical examination, the clinical voice laboratory, high-speed digital imaging, laryngeal electromyography,… and other contents.
Clinical Assessment of Voice Second Edition Clinical Assessment of Voice Second Edition Robert Thayer Sataloff, md, dma 5521 Ruffin Road San Diego, CA 92123 e-mail: info@pluralpublishing.com Website: http://www.pluralpublishing.com Copyright © 2017 by Plural Publishing, Inc Typeset in 10/12 Palatino by Flanagan’s Publishing Service, Inc Printed in Korea by Four Colour Print Group All rights, including that of translation, reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording, or otherwise, including photocopying, recording, taping, Web distribution, or information storage and retrieval systems without the prior written consent of the publisher For permission to use material from this text, contact us by Telephone: (866) 758-7251 Fax: (888) 758-7255 e-mail: permissions@pluralpublishing.com Every attempt has been made to contact the copyright holders for material originally printed in another source If any have been inadvertently overlooked, the publishers will gladly make the necessary arrangements at the first opportunity NOTICE TO THE READER Care has been taken to confirm the accuracy of the indications, procedures, drug dosages, and diagnosis and remediation protocols presented in this book and to ensure that they conform to the practices of the general medical and health services communities However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication The diagnostic and remediation protocols and the medications described not necessarily have specific approval by the Food and Drug administration for use in the disorders and/or diseases and dosages for which they are recommended Application of this information in a particular situation remains the professional responsibility of the practitioner Because standards of practice and usage change, it is the responsibility of the practitioner to keep abreast of revised recommendations, dosages, and procedures Library of Congress Cataloging-in-Publication Data Names: Sataloff, Robert Thayer, author Title: Clinical assessment of voice / Robert Thayer Sataloff Description: Second edition | San Diego, CA : Plural Publishing, [2017] | Clinical Assessment of Voice is part of a three-book student edition of selected chapters from the fourth edition of Professional voice: the science and art of clinical care | Includes bibliographical references and index Identifiers: LCCN 2017023705| ISBN 9781597568593 (alk paper) | ISBN 1597568597 (alk paper) Subjects: | MESH: Voice Disorders diagnosis | Voice physiology Classification: LCC RF510 | NLM WV 500 | DDC 616.85/5 dc23 LC record available at https://lccn.loc.gov/2017023705 Contents Foreword by Thomas Murry, PhD ix Preface xi Acknowledgments to the Second Edition xiii About the Author xv Contributors xix Dedication xxiii Chapter Patient History Robert Thayer Sataloff Chapter Special Considerations Relating to Members of the Acting Profession Bonnie N Raphael 25 Chapter Physical Examination Robert Thayer Sataloff 29 Chapter The Clinical Voice Laboratory Jonathan J Romak, Reinhardt J Heuer, Mary J Hawkshaw, and Robert Thayer Sataloff 43 Chapter High-Speed Digital Imaging Matthias Echternach 77 Chapter Evolution of Technology Jonathan J Romak and Robert Thayer Sataloff 91 Chapter Laryngeal Electromyography Robert Thayer Sataloff, Steven Mandel, and Yolanda D Heman-Ackah 97 Chapter Laryngeal Photography and Videography Eiji Yanagisawa, Ken Yanagisawa, and H Steven Sims 127 Chapter Laryngeal Computed Tomography Jean Abitbol, Albert Castro, Rodolphe Gombergh, and Patrick Abitbol 145 Chapter 10 Magnetic Resonance Imaging of the Voice Production System Matthias Echternach 171 Chapter 11 New Dimensions in Measuring Voice Treatment Outcomes and Quality of Life Michael S Benninger, Mausumi N Syamal, Glendon M Gardner, and Barbara H Jacobson 185 Chapter 12 Common Medical Diagnoses and Treatments in Patients With Voice Disorders: An Introduction and Overview Robert Thayer Sataloff, Mary J Hawkshaw, and Johnathan B Sataloff 197 Chapter 13 The Effects of Age on the Voice Robert Thayer Sataloff, Karen M Kost, and Sue Ellen Linville 221 v vi Clinical Assessment of Voice Chapter 14 Pediatric Voice Disorders Alexander Manteghi, Amy Rutt, Robert Thayer Sataloff 241 Chapter 15 Hearing Loss in Singers and Other Musicians Robert Thayer Sataloff, Joseph Sataloff, and Brian McGovern 257 Chapter 16 Endocrine Function Timothy D Anderson, Dawn D Anderson, and Robert Thayer Sataloff 275 Chapter 17 The Vocal Effects of Thyroid Disorders and Their Treatment Julia A Pfaff, Hilary Caruso-Sales, Aaron Jaworek, and Robert Thayer Sataloff 291 Chapter 18 Psychological Aspects of Voice Disorders Deborah Caputo Rosen, Reinhardt J Heuer, David A Sasso, and Robert Thayer Sataloff 303 Chapter 19 Allergy John R Cohn, Patricia A Padams, Mary J Hawkshaw, and Robert Thayer Sataloff 335 Chapter 20 Respiratory Dysfunction Robert Thayer Sataloff, John R Cohn, and Mary J Hawkshaw 341 Chapter 21 Pollution and Its Effects on the Voice Robert Thayer Sataloff 355 Chapter 22 Infectious and Inflammatory Disorders of the Larynx Catherine F Sinclair and Robert S Lebovics 369 Chapter 23 Laryngeal Papilloma Kevin P Leahy, Oren Friedman, and Robert Thayer Sataloff 387 Chapter 24 Sleep and the Vocal Performer Joanne E Getsy, Robert Thayer Sataloff, and Julie A Wang 399 Chapter 25 Reflux and Other Gastroenterologic Conditions That May Affect the Voice Robert Thayer Sataloff, Donald O Castell, Philip O Katz, Dahlia M Sataloff, and Mary J Hawkshaw 413 Chapter 26 Bodily Injuries and Their Effects on the Voice Robert Thayer Sataloff 505 Chapter 27 Performing Arts Medicine and the Professional Voice User: Risks of Nonvoice Performance William J Dawson, Robert Thayer Sataloff, and Valerie L Trollinger 509 Chapter 28 Neurologic Disorders Affecting the Voice in Performance Linda Dahl, Jessica W Lim, Steven Mandel, Reena Gupta, and Robert Thayer Sataloff 519 Chapter 29 Vocal Fold Paresis and Paralysis Adam D Rubin and Robert Thayer Sataloff 547 Chapter 30 Spasmodic Dysphonia Aaron J Jaworek, Daniel A Deems, and Robert Thayer Sataloff 565 Chapter 31 Structural Abnormalities of the Larynx Robert Thayer Sataloff 589 Chapter 32 Voice Impairment, Disability, Handicap, and Medical-Legal Evaluation Robert Thayer Sataloff 643 Contents vii Appendix I A. Patient History: Singers B. Patient History: Professional Voice Users 657 665 Appendix II A Reading Passages B Laryngeal Examination 673 675 Appendix III 677 679 683 693 697 699 Glossary Index A Sample Laryngologist’s Report B Strobovideolaryngoscopy Report C Objective Voice Analysis and Laryngeal Electromyography D Speech-Language Pathologist’s Report E Singing Voice Specialist’s Report F Acting Voice Specialist’s Report 701 721 Foreword Dr Robert Sataloff has devoted his professional career to the care and treatment of the voice He was a professional singer and singing teacher before he began his medical career Dr Sataloff’s dedication to the voice stems from his personal love and active involvement in singing and vocal pedagogy His medical and scientific interests in the voice developed during his residency as his musical colleagues solicited his medical advice Much to his surprise, he learned that there was not much written about the care of the voice, especially aspects of the singer’s voice So he pursued a fellowship in otology knowing how important the ear is to the voice While completing that fellowship his interest in voice surged to a point that he chose to pursue the study of voice with such a force that he has become the most prolific writer of voice books for laryngologists, speechlanguage pathologists and voice teachers In 1977, he began attending the meetings of the Voice Foundation in New York City His enthusiasm grew until he focused his primary interest in the development of new approaches for medical surgical and behavioral management of voice disorders With the support and influence of people such as Drs Wilbur J Gould, Friederic Brodnitz, Hans von Leden, and Paul Moore, among others, he combined his love for the voice and his medical practice into a premier center for the care of professional singers and other vocal performers from all over the world His clinical practice and pursuit of knowledge led him to publish his first paper on professional singers in 1981 entitled, “Professional Singers: The Science and Art of Clinical Care” and the first chapter on modern voice care in an otolaryngology textbook in 1986 He eventually became Chairman of the Board of Directors of the Voice Foundation in 1989 where he has since championed the need for interdisciplinary voice care through the annual Symposium on Care of the Professional Voice sponsored by the Voice Foundation and the monthly publication of the Journal of Voice of which he is currently Editor-in-Chief Gifted as a surgeon and skilled in the art of expression, whether it be through his singing or his lecturing, Dr Sataloff has taken the humble beginnings of the Voice Foundation and has made its influence felt around the world by physicians, speech-language pathologists, singing teachers, and vocal performers of all types from reggae to opera and from rap poets to the highest profile public speakers In addition, Dr Sataloff has trained many of the most influential laryngologists who specialize in the care of the professional voice A cursory review of any program from the Voice Foundation’s Symposium on Care of the Professional Voice attests to his influence in all aspects of voice care In Clinical Assessment of Voice, Second Edition, one of three student editions derived from chapters selected for speechlanguage pathology students and clinicians from the fourth edition of Professional Voice: The Science and Art of Clinical Care, Dr Sataloff brings together a dynamic group of professionals who share his interdisciplinary philosophy of voice care that he has espoused for over 30 years This volume is up to date with an international core of authors from varied disciplines, all actively engaged in the diagnosis and treatment voice disorders Clinical Assessment of Voice, Second Edition, includes chapters written by individuals with specialties in laryngology, vocal coaching and teaching of singing, voice science, and speech-language pathology, nursing and acoustics This volume mirrors the state of the art of voice care in the 21st century Throughout this book, we are reminded of the interdisciplinary care that is required in the assessment of voice disorders All aspects of voice assessment are presented in a coherent fashion Starting with an extensive case history and following with the physical examination, the objective documentation in the voice laboratory, and the latest diagnostic imaging with laryngeal computed tomography and strobovideolaryngoscopy, the chapters delineate the possible diagnoses and treatment approaches that currently represent the state of the art in assessment of voice disorders Added is the current information on the medical legal evaluation, now ever more important for the professional performer For the practicing otolaryngologist and speechlanguage pathologist, Clinical Assessment of Voice, ix 242 Clinical Assessment of Voice conditions such as croup Also, pediatric subglottic pressures are higher as compared with adults, partially secondary to recruitment from a larger percentage of pulmonary capacity.9 Assessment of the Child With a Vocal Disorder Vocal Fold Growth As with any medical complaint, a thorough and meticulous history is essential in the evaluation of pediatric dysphonia The physician, voice team, and office staff should establish rapport with the patient and family and promptly educate them about the office visit Such communication reduces the anxiety of both parent and child Standardized questionnaires are given to the patient (if old enough) and caregiver These are reviewed by the otolaryngologist, speech-language pathologist (SLP), and other members of the voice team to characterize the complaint, identify risk factors, and assess the impact of the dysphonia on the patient and family Information obtained during the history may help to narrow the differential diagnosis Past medical history including diagnoses of congenital defects or systemic illnesses is ascertained Surgery to the head, neck, brain and spine, thorax, abdomen, and even musculoskeletal system can impact the voice The surgical records should be obtained and reviewed when possible Environmental history is often underemphasized, and questions pertaining to living conditions in the home, at daycare, and at school should be asked when applicable Tobacco, allergen, chemical, and fume exposure should be investigated Special attention should be paid to professional or serious avocational voice use such as singing or acting; these activities necessitate additional history.16 The time of onset of dysphonia can help the practitioner separate dysphonia causes into general categories Dysphonia present at birth generally is associated with congenital pathology and some neurologic causes, although trauma, intubation, or even suction at the time of delivery can cause dysphonia Dysphonia acquired later may have many causes Iat- Puberty is associated with marked laryngeal development The length of the vocal folds is equal in both genders (6–8 mm) until the age of about 10 years However, thereafter there is significantly greater growth in boys than girls In a cadaver study of laryngeal dimensions, female postpubertal vocal folds were 24% longer compared to their prepubertal counterparts, versus 67% longer in males.10 The cartilaginous portion of the vocal fold also lengthens with age, but relatively less, so that the ratio of musculomembranous-to-cartilaginous vocal fold is 1.5:1 in the newbom, 4:1 in the adult female, and 5.5:1 in the adult male (Table 14–1).11–15 Frequency of the voice in children is characteristically different from the adult voice As the child grows, mean fundamental frequency of speech drops gradually, with a more marked change at puberty in boys By years of age, it is approximately 275 Hz.12 During childhood, the physiologic frequency range (the highest and lowest sounds a child can produce) remains fairly constant, but the musical frequency range increases Thus, between the ages of and 16, the important developmental change is not the absolute range (constant at about 2½ octaves) but rather improved control, efficiency, and quality.12 The development of the “Adam’s Apple” results from a testosterone-driven increase in the anteroposterior length of the thyroid ala, associated with pitch change As noted above, the microstructure of the vocal folds becomes more refined with the differentiation of layers Finally, the arytenoid cartilages enlarge along with expansion of the intrinsic muscles and ligaments of the larynx.13,14 History Table 14–1. Differences Between the Pediatric and Adult Larynx Features Pediatric Adult Position Higher (cricoid at T4) Lower (cricoid at T6) Shape Omega-shaped epiglottis More open Vocal Fold Immature Mature: layers Vocal Folds Membranous:Cartilage Ratio 1.0:1.5 Membranous:Cartilage Ratio 1.0:5.0 Source: Adapted from Possamai and Hartley.15 14. Pediatric Voice Disorders rogenic causes typically have an associated event that predated the dysphonia immediately, or by several days, weeks, or months, such as subglottic stenosis developing from endotracheal intubation Infectious cases (except laryngeal papillomatosis) generally are accompanied by systemic signs of illness A raspy voice in a child with abusive voice use may be associated with anatomic causes such as vocal fold nodules Some causes of dysphonia, such as reflux, may be otherwise asymptomatic, presenting primarily with dysphonia It is also necessary to differentiate intermittent or recurrent dysphonia from persistent or progressive dysphonia Progressive dysphonia may indicate a graver and potentially life-threatening problem such as enlarging papillomata or neoplasm Stridor always requires an expedited evaluation Stridor may be inspiratory, expiratory, or biphasic Inspiratory stridor classically implies a laryngeal obstacle, while expiratory stridor implies a tracheobronchial obstruction Biphasic stridor suggests a glottic and/or subglottic abnormality, such as subglottic stenosis or papillomatosis Swallowing difficulties, choking, or chronic cough may suggest vocal fold paralysis Many pathologies may impact the larynx of a child, just as they can in an adult.16,17 It is necessary to inquire about symptoms suggesting laryngopharyngeal reflux, which may lead to local inflammation and dysphonia Globus sensation and throat clearing may suggest laryngeal edema from laryngopharyngeal reflux (LPR) LPR and gastroesophageal reflux disease (GERD) are common in infants, often manifested by frequent spitting up and wet sounding burps Reflux is associated with chronic hoarseness and “vocal nodules” in children.18 Respiratory pathology also may cause dysphonia via several pathways Underlying asthma can lead to hoarseness through compromise of the power source of the voice that leads to compensatory muscle tension dysphonia (MTD), and asthma treatment such as corticosteroid inhalers also is known to cause dysphonia.19 Restrictive lung disease will reduce thoracic pressure, thereby affecting support and secondarily the strength of the voice and leading to hyperfunctional compensation Less direct symptoms also may have a bearing; for example, sensorineural hearing loss may predispose the child to shout, leading to dysphonia from vocal abuse Similarly, children from larger sibling groups have a higher rate of dysphonia associated with misuse.20 Abnormalities in any organ system may be responsible for a voice complaint; so, the history has to be comprehensive to avoid missing endocrinological, 243 musculoskeletal, gastroenterologic, pulmonary, allergic, psychological, and other causes, just as in adults Serious Avocational or Professional Voice Use Like adults, children may use their voices avocationally or professionally Many are very serious about their voice activities Some have received training, but many have not Children may be involved in acting, singing, television commercials, voiceovers, and many of the other activities that we usually associate with adults While this topic will not be covered in detail in this chapter, and many considerations may be inferred from the discussions of adult professional users found elsewhere in this book, it is important for the health-care provider to include questions about avocational and professional voice use in the history of a child with voice complaints Dysphonia is not uncommon in young singers For example, in a survey of young choir singers, more than half of 129 respondents reported having experienced vocal difficulties (particularly older adolescents).21 Physicians need to consider each child’s vocal demands, training, and aspirations, and individualize treatment accordingly As noted previously,22 in general, the sophisticated, multidisciplinary teams and protocols that are now routine for adult voice patients have not been available widely in pediatric otolaryngology divisions This deficiency has been recognized for at least decades It should be noted that the problem exists not only for pediatric voice disorders, but also for all areas of pediatric arts medicine Although arts medicine centers have been established since the early 1980s and adult arts medicine is a well-established field,23 there is still no arts medicine center based at a pediatric hospital Directed Physical Examination A general otolaryngologic examination should be performed, including examination of the ears and hearing There are many head and neck physical findings that may impact laryngeal function and vocal quality For example, adenotonsillar hypertrophy and nasal obstruction may result in a hyponasal resonance In contrast, clefting and hypotonia of the soft palate may be responsible for a hypernasal resonance Both may be perceived as a vocal disorder Facial anomalies may indicate an underlying syndrome associated with laryngeal abnormalities 244 Clinical Assessment of Voice Voice assessment is performed best in collaboration with a SLP or phoniatrist with training in voice disorders Specialized SLPs have the skills to evaluate dysphonia, common speech and language disorders (eg, articulation error, oral motor dyspraxia, abnormal resonance, higher function language difficulties), and to define and treat their functional consequences.24 Singing-voice specialists, acting-voice specialists, and voice scientists also can provide valuable insights and interventions Assessment of the voice should be thorough and be performed perceptually and objectively The perceptual evaluation is completed primarily with a SLP or phoniatrist The most commonly used rating scales are the GRBAS (grade, roughness, breathiness, asthenia, strain), Buffalo III Voice Profile, and CAPE-V (Consensus Auditory-Perceptual Evaluation of Voice).25–27 While perceptual assessments are vital, they are subjective; therefore, they may vary from one listener to the next Furthermore, unintentional bias may occur when the physician and SLP hope to show a noticeable improvement in their patients These hindrances may be prevented by the use of multiple, blind trained evaluations and by computer-assisted and other objective voice analyses Pediatric normative data for different voice categories have been developed,28 and there are now several different software and hardware systems available that are tailored to the evaluation of these parameters Endoscopy and Stroboscopy Upper airway endoscopy in the pediatric patient can be a challenge The pediatric otolaryngologist or laryngologist must be temperate, methodical, and adept with children Traditionally, the pediatric larynx has been examined under general anesthesia Of course, while providing excellent visualization of structural anomalies, little information is gained regarding function This method may be used in younger or poorly compliant children, but all efforts should be made to examine the pediatric patient awake In patients who are compliant, awake, flexible laryngoscopy is capable of identifying most focal laryngeal lesions, providing dynamic neurolaryngeal evaluation, and providing fairly adequate stroboscopy quality Available choices include the 2.2 mm or mm, flexible endoscope, although some children will tolerate larger adult endoscopes The optics are better with the larger endoscope However, children between and years may be less tolerant of the procedure Awake rigid laryngoscopy requires a higher level of cooperation from the child, and it is typically reserved for children older than years This procedure involves asking the child to stick out the tongue, grasping the tongue with gauze, and placing a laryngeal telescope in the mouth to visualize the larynx These images provide excellent information regarding the structure and mucosal movement of the vocal folds A software package designed to capture and store images and video digitally is invaluable for a pediatric practice Many of the glottic images are brief, and the ability to pause and playback video in slow motion is indispensable Editing short segments so that they are repeated multiple times (looped) can be extremely helpful Because of the limitations of stroboscopy in young children, especially the short phonation times, high-speed video is sometimes a valuable adjunct for evaluating the vibratory margin and mucosal wave It should be remembered that the endoscope tip gets quite hot If held close to the pediatric larynx, it is hot enough to cause injury with prolonged attempts to see Further Testing Laryngeal electromyography (LEMG) is performed with electrodes inserted into the thyroarytenoid, posterior cricoarytenoid, cricothyroid, and sometimes other muscles.29 LEMG is the best test to define the underlying neurophysiology of abnormal laryngeal motion In adults, LEMG can be performed in almost all patients with limited or no topical anesthesia However, children are generally frightened of needles and not tolerate painful tests Thus, pretreatment with a sedative may be helpful As a last resort, LEMG may be performed under light general anesthesia LEMG can evaluate different waveforms while the tested muscle is at rest, mildly contracting, or maximally contracting The most classic use of LEMG is in the evaluation of unilateral vocal cord immobility, distinguishing mechanical from neurological causes, and helping to predict the return of function There may be evidence to suggest recovery may be apparent on LEMG months before movement becomes visible on laryngoscopy, thus aiding decisions regarding management.30 The clinical value of LEMG has been well established in adults,31 and LEMG should have the same utility in children Further testing to evaluate for reflux can be considered, especially when trial therapy has failed Esophageal manometry and 24-hour pH impedance testing can provide invaluable information.32 Esophageal biopsy and bronchoalveolar lavage also can be used but may correlate poorly with endoscopic findings.33 14. Pediatric Voice Disorders Common Disorders Vocal Fold Nodules Vocal nodules are said to be the most common cause of dysphonia in children (Figure 14–1).34 Approximately 40% of children who present to a pediatric voice clinic complaining of hoarseness will receive a diagnosis of vocal fold nodules.35,36 Unfortunately, few of these children undergo strobovideolaryngoscopy So, the accuracy of the diagnosis of “nodules” is suspect Many of these lesions may be cysts, polyps, or other masses Nevertheless, there is still an unfortunate tendency among physicians to call all bumps on the vocal folds laryngeal “nodules.” They generally affect boys more than girls.37 There is a bimodal presentation in age from to years and then again at to 10 years However, after the age of 13, dysphonia from vocal nodules becomes a malady primarily of young women Nodules are fibrotic masses with fibronectin deposits located superficially in the vocal fold often tied with basement membrane zone injury as indicated by thick collagen type IV bands,38 as well as basement membrane reduplication They are classically located in the midportion of the musculomembranous portion of the vocal fold and are generally fairly symmetric The typical history of the child with vocal nodules consists of intermittent hoarseness that worsens with vocal use and improves with voice rest Nodules are thought to be the result of vocal abuse or misuse; however, the exact inciting events leading to cyclic injury are not completely understood Shah et al37 found that 75% of children with vocal nodules exhibited significant muscle tension dysphonia This Figure 14–1. Small vocal fold nodules (Republished with permission from Sataloff et al.34) 245 hyperfunction correlated with nodule size, but it is unclear whether the hyperfunctioning was a result of the nodule size or vice versa They also found 25% of children with nodules had signs of laryngopharyngeal reflux, but there was no correlation between the severity of reflux and nodule size In addition, the diagnosis of reflux (or nonreflux) was not confirmed objectively Treatment of vocal fold nodules begins with vocal hygiene, voice therapy, behavioral management, and proton pump inhibitors when LPR is present Vocal nodules respond well to voice therapy, and surgical treatment is rarely indicated, although the evidence for this practice is lacking with no trial eligible for inclusion in a recent Cochrane review of surgical versus nonsurgical interventions for vocal nodules.39 One barrier is the problem of establishing an accurate diagnosis Another barrier is the lack of a widely accepted rating scale for vocal nodules in children, thus making it problematic to compare treatment plans Shah et al40 studied their experience with a grading scale based on static images, while Nuss et al41 recently described a rating scale based on the review of digital video clips of examinations The results of Nuss’s study showed a high level of agreement between experienced and inexperienced raters Further studies are required to determine the efficacy of these scales In adolescents, voice therapy is comparable to that used with adults; however, different tactics are required in younger children It is key to reduce voice strain via encouragement to eliminate shouting, muscle tension dysphonia, forceful whispering, throat clearing, and cough One study found vocal hygiene alone did not improve vocal nodules, but voice therapy did have a positive impact, with increasing value associated with more sessions attended.42 Classic teaching suggests that most vocal nodules improve during puberty, which fits with the substantial changes that transpire in the musculomembranous vocal fold during this phase It is important to note, however, that not all resolve, as Mori found 12% of vocal nodules did not improve after puberty.42 Surgery has a limited role, due to concerns over scarring resulting in poor voice outcomes There are currently no generally accepted data on which to base the decision of when or how to remove nodules in children Even identification of nodules may not always be straightforward as noted above; one study found microlaryngoscopy evidence of cysts, sulci, and polyps in children with a prior diagnosis of nodules.43 It is common in adults and children for a cyst to be present on one vocal fold with a reactive nodule on the contralateral fold, having been misdiagnosed as bilateral nodules and possibly explaining 246 Clinical Assessment of Voice Anterior glottic webs may be congenital or acquired Webs may be asymptomatic or may cause dysphonia by interfering with airflow across the membranous vocal fold, preventing the mucosal wave from propagating, and by impairing glottic closure Acquired glottic webs are generally iatrogenic, as with repeated resections of recurrent respiratory papillomata Congenital glottic webs may be the result of incomplete recannulization of the embryonic larynx The extent of webbing can range from anterior webbing to nearly complete occlusion of the larynx, and they may be associated with thickening of the anterior cricoid cartilage Congenital webs typically present with a high-pitched, weak cry at birth, and an association with velocardiofacial syndrome has been reported.45 Glottic webs should be differentiated from mucosal bridges (Figure 14–3), which may be mistaken for webs but which are much easier to treat successfully surgically Rigid endoscopy in the operating room often is needed to evaluate the glottic and subglottic extent of webs Seymour Cohen proposed a classification system for glottic webs (Table 14–2).46 A web that causes airway obstruction and hoarseness warrants prompt surgical intervention Excision of the web, however, often is followed by reformation of the web Thus, it is often advisable to place a keel or similar separator to keep the edges of the anterior vocal fold from rescarring together Surgical approaches can be either endoscopic or via laryngofissure The thickness of the web and associated subglottic and supraglottic extension are the key factors in determining appropriate management If the web does not extend below the inferior edge of the true vocal folds and the posterior larynx is normal, than an endoscopic approach often will be successfu1.47 Endoscopic techniques include an endolaryngeal mucosal flap,48 endoscopic placement of a keel,49 endoscopic modification of Dedo technique described by Mouney and Lyons,50 and a 2-stage procedure with placement of a flanged prosthesis.51 External A B a poor response to voice therapy The preferred technique for removal of nodules is excision using a mini-microflap.44 Vocal Fold Cysts Vocal fold cysts are another cause of dysphonia, and may be either acquired or congenital (Figure 14–2) Congenital cysts typically are either mucus-filled cysts or epidermal cysts filled with keratinous material They cause dysphonia by increasing the mass of the vocal fold and impairing glottic closure and mucosal wave Cysts are sometimes difficult to differentiate from nodules in the pediatric larynx, as there is often a contralateral reactive vocal mass Vocal fold cysts usually not resolve with voice therapy, although voice may improve through therapy due to decrease in the edema surrounding the cyst as well as improvement in the reactive mass If substantial dysphonia persists after voice therapy, surgical excision is generally appropriate Anterior Glottic Web Figure 14–2. Strobovideolaryngoscopy shows a cyst in the left striking zone (A) and a reactive mass on the right (B) (Republished with permission from Sataloff et al.34) 247 14. Pediatric Voice Disorders Figure 14–3. Stroboscopy shows multiple varices running perpendicular to the vibrating surface of each vocal fold in a patient who also has a mucosal bridge (Republished with permission from Sataloff et al.34) Table 14–2. Glottic Web Classification, as Described by Cohen46 Severity Extent of Glottic Involvement (%) Subglottic Extent Visible Cords Symptoms Little or none Present Clear airway, mild dysphonia Type